Dr. Dy is an Assistant Professor and the primary physician for the paliative care consultation programs for Johns Hopkins Medicine. Through this award, Dr. Dy would like to conduct health services and decision-making research on an important issue in cancer palliative care: the appropriate use of artificial nutrition at the end of life. She will have the mentorship and support of experts in oncology, palliative care, geriatrics and artificial nutrition, and health services research methods. To complement her research, Dr. Dy will take courses in qualitative research, communication, and advanced health services research and biostatistics methods. The care of terminally ill patients with cancer often involves difficult choices. The use of technology such as artificial nutrition at the end of life is often not helpful and may be detrimental to quality of life. Through a series of 3 research projects, this grant will examine the potential contribution of interventions to improve the appropriateness of technologic use at three different levels. First, on the individual patient level, we will explore the decision-making process for artificial nutrition in terminally ill cancer patients, as well as patients' and surrogates' perceptions of the process and how it might be improved. Secondly, on the hospital level, we will explore whether the growth in palliative care consultation services has impacted the use of artificial nutrition at the local level. Finally, on the regional level, we will examine whether the growth of hospice services has impacted the use of artificial nutrition. The combination of qualitative and quantitative primary data collection and research utilizing existing data sources, the excellent mentorship of senior scientists, the available coursework, research conferences, and observation experiences, and the supportive environment at Johns Hopkins University will provide Dr. Dy with the skills she needs to develop into an independent clinical researcher in oncology palliative care decision-making and health services research.